Pap Smear

What Is a Pap Smear?

A Pap smear (Pap test) is a test of a sample of cells taken from a woman's
cervix. The test is used to look for changes in the cells of the cervix that
show cervical cancer or conditions that may develop into cancer.
It is the best tool to detect precancerous conditions and hidden, small tumors
that may lead to cervical cancer. If detected early, cervical cancer can be
cured.
Pap screen testing should begin at age 21. Routine screening is
recommended every two years for women 21-29 years old. For certain
women 30 years and older who have had three consecutive normal
screening test results, testing can be done every three years.

Essential Screening Tests Every Woman Needs

How Is a Pap Smear Performed?

The Pap smear is done during a pelvic exam. A doctor uses a device called a
speculum to widen the opening of the vagina so that the cervix can be
examined. A plastic spatula and small brush are used to collect cells from the
cervix. After the cells are taken, they are placed into a solution. The solution
is sent to a lab for testing.

Is the Pap Smear Painful?

A Pap smear is not painful, but the pelvic exam may be a little
uncomfortable.

When Will I Know the Results of the Pap Smear?

It may take several weeks to get the test results. If you haven't heard from
your doctor's office after 3 weeks, give them a call to see if your results have
come back.

What Do the Results of a Pap Smear Mean?

A normal Pap smear means the cells from the cervix look normal. An
abnormal Pap smear means the cells do not look normal. Sometimes repeat
Pap smears are needed. Different tests also may need to be done, such as a
colposcopy (the use of a special microscope to examine the cervix and
vagina). Pap smears can occasionally show signs of infection but cannot be
relied on to screen for sexually transmitted diseases (STDs). Other tests are
necessary to determine the presence of an STD. There are several things you
can do to help make the Pap smear as accurate as possible. These include
avoidance of sex, douching, and vaginal creams for 48 hours before the test.

What Happens If the Results Are Abnormal?

An abnormal Pap smear does not necessarily mean that cancer cells were
found during the examination. There are many causes for abnormal Pap
smear results. Your doctor will evaluate the results to determine if further
testing is necessary.

Why Would I Need to Repeat the Pap Smear?

A repeat Pap smear may be necessary if you had an infection at the time of
the test or if there were not enough cells collected during the test. Since
decreased levels of the female hormone estrogen also can influence Pap
smear results, menopausal women may need to take estrogen before they
repeat the test.
If the results of the repeat Pap smear are still abnormal, your doctor may
recommend that you have a colposcopy to further evaluate the problem.

Why do I need a Pap test?

A Pap test can save your life. It can find the earliest signs of cervical cancer.
If caught early, the chance of curing cervical cancer is very high. Pap tests
also can find infections and abnormal cervical cells that can turn into cancer
cells. Treatment can prevent most cases of cervical cancer from developing.

Getting regular Pap tests is the best thing you can do to prevent cervical
cancer. In fact, regular Pap tests have led to a major decline in the number
of cervical cancer cases and deaths.

Do all women need Pap tests?

It is important for all women to have Pap tests, along with pelvic exams, as
part of their routine health care. You need a Pap test if you are 21 years or
older.

Women who have gone through menopause (when a woman's periods stop)
still need regular Pap tests. Women ages 65 and older can talk to their
doctor about stopping after at least 3 normal Pap tests and no abnormal
results in the last 10 years.

How often do I need to get a Pap test?

It depends on your age and health history. Talk with your doctor about what
is best for you. Most women can follow these guidelines:

• Starting at age 21, have a Pap test every 2 years.

• If you are 30 years old and older and have had 3 normal Pap tests
for 3 years in a row, talk to your doctor about spacing out Pap tests to
every 3 years.
• If you are over 65 years old, ask your doctor if you can stop having
Pap tests.

Ask your doctor about more frequent testing if:

• You have a weakened immune system because of organ

transplant, chemotherapy, or steroid use
• Your mother was exposed to diethylstilbestrol (DES) while pregnant
• You are HIV-positive

Women who are living with HIV, the virus that causes AIDS, are at a higher
risk of cervical cancer and other cervical diseases. The U.S. Centers for
Disease Control and Prevention recommends that all HIV-positive women get
an initial Pap test, and get re-tested 6 months later. If both Pap tests are
normal, then these women can get yearly Pap tests in the future.

Who does not need regular Pap tests?

The only women who do not need regular Pap tests are:

• Women over age 65 who have had 3 normal Pap tests and in a row and
no abnormal test results in the last 10 years, and have been told by
their doctors that they don't need to be tested anymore.
• Women who do not have a cervix and are at low risk for cervical
cancer. These women should speak to their doctor before stopping
regular Pap tests.
I had a hysterectomy. Do I still need Pap tests?
It depends on the type of hysterectomy (surgery to remove the uterus) you
had and your health history. Women who have had a hysterectomy should
talk with their doctor about whether they need routine Pap tests.

Usually during a hysterectomy, the cervix is removed with the uterus. This is
called a total hysterectomy. Women who have had a total hysterectomy for
reasons other than cancer may not need regular Pap tests. Women who have
had a total hysterectomy because of abnormal cells or cancer should be
tested yearly for vaginal cancer until they have three normal test results.
Women who have had only their uterus removed but still have a cervix need
regular Pap tests. Even women who have had hysterectomies should see
their doctors yearly for pelvic exams.

How can I reduce my chances of getting cervical cancer?

Aside from getting Pap tests, the best way to avoid cervical cancer is by
steering clear of the human papillomavirus (HPV). HPV is a major cause of
cervical cancer. HPV infection is also one of the most common sexually
transmitted infections (STI). So, a woman boosts her chances of getting
cervical cancer if she:

• Starts having sex before age 18

• Has many sex partners
• Has sex partners who have other sex partners
• Has or has had a STI

What should I know about human papillomaviruses (HPV)?

Human papillomaviruses (HPV) are a group of more than 100 different
viruses.

• About 40 types of HPV are spread during sex.

• Some types of HPVs can cause cervical cancer when not treated.
• HPV infection is one of the most common sexually transmitted
infections (STI).
• About 75 percent of sexually active people will get HPV sometime in
their life.
• Most women with untreated HPV do not get cervical cancer.
 • Some HPVs cause genital warts but these HPVs do not cause cervical
cancer.
• Since HPV rarely causes symptoms, most people don't know they have
the infection.

How would I know if I had human papillomavirus (HPV)?

Most women never know they have HPV. It usually stays hidden and doesn't
cause symptoms like warts. When HPV doesn't go away on its own, it can
cause changes in the cells of the cervix. Pap tests usually find these
changes.

How do I prepare for a Pap test?

Many things can cause wrong test results by washing away or hiding
abnormal cells of the cervix. So, doctors suggest that for 2 days before the
test you avoid:

• Douching
• Using tampons
• Using vaginal creams, suppositories, and medicines
• Using vaginal deodorant sprays or powders
• Having sex

Should I get a Pap test when I have my period?

No. Doctors suggest you schedule a Pap test when you do not have your
period. The best time to be tested is 10 to 20 days after the first day of your
last period.

How is a Pap test done?

Your doctor can do a Pap test during a pelvic exam. It is a simple and quick
test. While you lie on an exam table, the doctor puts an instrument called a
speculum into your vagina, opening it to see the cervix. She will then use a
special stick or brush to take a few cells from inside and around the cervix.
The cells are placed on a glass slide and sent to a lab for examination. While
usually painless, a Pap test is uncomfortable for some women.

When will I get the results of my Pap test?

Usually it takes 3 weeks to get Pap test results. Most of the time, test results
are normal. If the test shows that something might be wrong, your doctor will
contact you to schedule more tests. There are many reasons for abnormal
Pap test results. It usually does not mean you have cancer.
What do abnormal Pap test results mean?
It is scary to hear that your Pap test results are "abnormal." But abnormal
Pap test results usually do not mean you have cancer. Most often there is a
small problem with the cervix.

Some abnormal cells will turn into cancer. But most of the time, these
unhealthy cells will go away on their own. By treating these unhealthy cells,
almost all cases of cervical cancer can be prevented. If you have abnormal
results, to talk with your doctor about what they mean.

My Pap test was "abnormal," what happens now?

There are many reasons for "abnormal" Pap test results. If results of the Pap
test are unclear or show a small change in the cells of the cervix, your doctor
will probably repeat the Pap test.

If the test finds more serious changes in the cells of the cervix, the doctor
will suggest more powerful tests. Results of these tests will help your doctor
decide on the best treatment. These include:

• Colposcopy: The doctor uses a tool called a colposcope to see the

cells of the vagina and cervix in detail.
• Endocervical curettage: The doctor takes a sample of cells from the
endocervical canal with a small spoon-shaped tool called a curette.
• Biopsy: The doctor removes a small sample of cervical tissue. The
sample is sent to a lab to be studied under a microscope.

The FDA recently approved the LUMA Cervical Imaging System. The doctor
uses this device right after a colposcopy. This system can help doctors see
areas on the cervix that are likely to contain precancerous cells. The doctor
uses this device right after a colposcopy. This system shines a light on the
cervix and looks at how different areas of the cervix respond to this light. It
gives a score to tiny areas of the cervix. It then makes a color map that helps
the doctor decide where to further test the tissue with a biopsy. The colors
and patterns on the map help the doctor tell between healthy tissue and
tissue that might be diseased.

My Pap test result was a "false positive." What does this mean?
Pap tests are not always 100 percent correct. False positive and false
negative results can happen. This can be upsetting and confusing. A false
positive Pap test is when a woman is told she has abnormal cervical cells,
but the cells are really normal. If your doctor says your Pap results were a
false positive, there is no problem.

A false negative Pap test is when a woman is told her cells are normal, but in
fact, there is a problem with the cervical cells that was missed. False
negatives delay the discovery and treatment of unhealthy cells of the cervix.
But, having regular Pap tests boosts your chances of finding any problems. If
abnormal cells are missed at one time, they will probably be found on your
next Pap test.

The Papanicolaou test (also called Pap smear, Pap test, cervical
smear, or smear test) is a screening test used in gynecology to detect
premalignant and malignant (cancerous) processes in the ectocervix.
Significant changes can be treated, thus preventing cervical cancer. The test
was invented by and named after the prominent Greek doctor Georgios
Papanikolaou. An anal Pap smear is an adaptation of the procedure to screen
and detect anal cancers.
In taking a Pap smear, a tool is used to gather cells from the outer opening of
the cervix (Latin for "neck") of the uterus and the endocervix. The cells are
examined under a microscope to look for abnormalities. The test aims to
detect potentially pre-cancerous changes (called cervical intraepithelial
neoplasia(CIN) or cervical dysplasia), which are usually caused by sexually
transmitted human papillomaviruses (HPVs). The test remains an effective,
widely used method for early detection of pre-cancer and cervical cancer.
The test may also detect infections and abnormalities in the endocervix
and endometrium.
In general, in countries where Pap smear screening is routine, it is
recommended that females, age 25 to 65, who have had sex seek regular
Pap smear testing. Guidelines on frequency vary, from annually to every five
years. If results are abnormal, and depending on the nature of the
abnormality, the test may need to be repeated in six to twelve months. If the
abnormality requires closer scrutiny, the patient may be referred for detailed
inspection of the cervix by colposcopy. The patient may also be referred
for HPV DNA testing, which can serve as an adjunct to Pap testing.
Indication
Screening guidelines vary from country to country. In general, screening
starts about age 20 or 25 and continues until about age 50 or 60.
Women should wait a few years after they first have intercourse before they
start screening. For example, United States Preventive Services Task
Force (USPSTF) recommends waiting three years. American Congress of
Obstetricians and Gynecologists (ACOG) recommends starting screening at
age 21 (since that is a few years after initial sex for most American
women). Many other countries wait until age 25 or later to start screening.
For instance, England starts screening at age 25.
Most women contract HPV soon after becoming sexually active. It takes an
average of a year, but can take up to four years, for a woman's immune
system to control the initial infection. Screening during this period may show
this immune reaction and repair as mild abnormalities, which are usually not
associated with cervical cancer, but could cause the woman stress and result
in further tests and possible treatment. Cervical cancer usually takes time to
develop, so delaying the start of screening a few years poses little risk of
missing a potentially precancerous lesion. For instance, screening women
under age 25 does not decrease cancer rates under age 30.
There is little or no benefit to screening women who have not had sexual
contact. HPV can be transmitted in sex between women, so women who
have only had sex with other women should be screened, although they are
at somewhat lower risk for cervical cancer.
Guidelines on frequency of screening vary—typically every three to five
years for those who have not had previous abnormal smears. Some older
recommendations suggested screening as frequently as every one to two
years,] but acknowledge that most women can be screened less often. Some
guidelines recommend more frequent screening for younger women, for
instance in England, screening is recommended every 3 years for women
under 50, and every 5 years for those over.
Guidelines vary on when to stop screening. There is probably no benefit
screening women aged 60 or over whose previous tests have been
negative. If a woman's last three Pap results were normal, she can stop at
age 65, according to the USPSTF, ACS says 70, ACOG says 65 or 70, and
England’s NHS says 64. There is no need to continue screening after a
complete hysterectomy for benign disease.
Pap smear screening is still recommended for those who have
been vaccinated against HPV,[8] since the vaccines do not cover all of the
HPV types that can cause cervical cancer. Also, the vaccine does not protect
against HPV exposure before vaccination.
More frequent Pap smears may be needed to follow-up after an abnormal
Pap smear, or after treatment for abnormal Pap or biopsy results, or after
treatment for cancer.
Procedure

For best results, a Pap test should not occur when a woman is menstruating.
However, Pap smears can be performed during a woman's menstrual period,
especially if the physician is using a liquid-based test; if bleeding is
extremely heavy, endometrial cells can obscure cervical cells, and it is
therefore inadvisable to have a Pap smear if bleeding is excessive.
The patient's perception of the procedure ranges from no discomfort at all to
severe discomfort (especially in women with cervical stenosis). Many women
experience spotting or mild cramping afterward.
The physician or operator collecting a sample for the test inserts
a speculum into the patient's vagina, to allow access to the cervix. Samples
are collected from the outer opening or os of the cervix using an Aylesbury
spatula and an endocervical brush is rotated in the cavity of the cervix. The
cells are placed on a glass slide and checked for abnormalities in
the laboratory.
A plastic-fronded broom is sometimes used in place of the spatula and brush.
The broom is not as good a collection device, since it is much less effective
at collecting endocervical material than the spatula and brush. The broom is
used more frequently with the advent of liquid-based cytology, although
either type of collection device may be used with either type of cytology.
The sample is stained using the Papanicolaou technique, in
which tinctorial dyes and acids are selectively retained by cells. Unstained
cells cannot be visualized with light microscopy. The stains chosen by
Papanicolaou were selected to highlight cytoplasmic keratinization, which
actually has almost nothing to do with the nuclear features used to make
diagnoses now.
In some cases, a computer system may pre-screen the slides, indicating
some that do not need examination by a person, or highlighting areas for
special attention. The sample is then usually screened by a specially trained
and qualified cytotechnologist using a light microscope. The terminology for
who screens the sample varies according to the country; in the UK, the
personnel are known as Cytoscreeners, Biomedical
scientists (BMS), Advanced Practitioners and Pathologists. The latter two take
responsibility for reporting the abnormal sample which may require further
investigation.

Results
In screening a general or low-risk population, most Pap results are normal.
In the United States, about 2-3 million abnormal Pap smear results are found
each years. Most abnormal results are mildly abnormal (ASC-US (typically 2-
5% of Pap results) or low-grade squamous intraepithelial lesion (LSIL) (about
2% of results)), indicating HPV infection. Although most low-grade cervical
dysplasias spontaneously regress without ever leading to cervical cancer,
dysplasia can serve as an indication that increased vigilance is needed.
In a typical scenario, about 0.5% of Pap results are high-grade SIL (HSIL), and
less than 0.5% of results indicate cancer; 0.2 to 0.8% of results indicate
Atypical Glandular Cells of Undetermined Significance (AGC-NOS).[citation needed]
As liquid based preparations (LBPs) become a common median for testing,
atypical result rates have increased. The median rate for all preparations
with low-grade squamous intraepithelial lesions using LBPs was 2.9%
compared with a 2003 median rate of 2.1%. Rates for high-grade squamous
intraepithelial lesions (median, 0.5%) and atypical squamous cells have
changed little.
Abnormal results are reported according to the Bethesda system. They
include:

 Squamous cell abnormalities (SIL)

 Atypical squamous cells of undetermined significance (ASC-US)
 Low-grade squamous intraepithelial lesion (LGSIL or LSIL)
 Atypical squamous cells - cannot exclude HSIL (ASC-H)
 High-grade squamous intraepithelial lesion (HGSIL or HSIL)
 Squamous cell carcinoma
 Glandular epithelial cell abnormalities
 Atypical Glandular Cells not otherwise specified (AGC or AGC-NOS)

Endocervical and endometrial abnormalities can also be detected, as can a

number of infectious processes, including yeast, herpes simplex virus and
trichomoniasis. However it is not very sensitive at detecting these infections,
so absence of detection on a Pap does not mean absence of the infection.